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Monday, August 31

The following comment was left at RBO blog in response to my post "Dealing with H1N1 swine flu outbreaks in U.S. schools: CDC advice about non-medical strategies and what's wrong with it."

Author: STOP THE VAX"Vaccines are POISON. The only one[s] who benefit from vaccines are PHARMACEUTICALS. Lots of Vitamin D will protect you from the flu and many other diseases. DON'T be fooled by paid off media hype. STOP the sickening assault on humanity." (1)

Unlikely the author bothered to read my post. The comment seems a stock blurb for insertion on any blog that mentions swine flu. But I decided to pretend there was a thinking person behind the comment:

TO: STOP THE VAX

You're overlooking certain facts about the era during the 1918-20 swine flu pandemic, which reportedly got off the ground as much as two years earlier with a very mild form of the swine flu strain:

The peoples who were worst hit by the virus were Pacific islanders. They lived in sunlight year round. They practically oozed Vitamin D. And they had very healthy fish-based diets and plenty of fresh fruits and vegetables.

In those days many people in the USA, even those who lived in cities, got plenty of sunlight so they were not deficient in Vitamin D.

And peoples in the USA got plenty of calcium and magnesium and plenty of whole, unprocessed grains. Because the soils they grew vegetables and fruits on weren't virtually depleted of trace minerals, as many soils are today, the produce was in better shape nutritionally than the modern versions. And of course the produce wasn't sprayed with tons of pesticides and other chemicals.

The Americans in those days ate free-range chickens that were free of antibiotics, and the eggs from those chickens were chock-full of lecithin and 'good' fatty acids. The Americans ate other meats as well, pork and beef, and fish, that were also free of antibiotics and other chemicals present in today's foods.

Yet despite their wholesome diet, Americans died in droves from swine flu. And many of those victims were young people with strong immune systems and they weren't prone to the range of immune-compromised illnesses, such as diabetes, that are the bane of life for many modern Americans.

As for China and India -- home to great curative concoctions that go back thousands of years -- the Chinese and Indians also died from the 1918 swine flu virus.

So what are you going to tell me now? That there's a special nutrient never before available outside the remotest region of Tibet, until a natural supplement website started selling it, which can prevent influenza infection?

There are still mysteries of genetics; scientists still don't know why flu viruses strike some people and leave others alone. But proper nutrition can no more protect a person from being attacked by a flu virus than it can prevent electrocution, if a person steps on a live wire resting in a puddle of water.

Nor can nutritional supplements protect the immune system from generating a reaction to an unrecognized viral invader -- a reaction that can be so violent it kills the host human or maims him for life.

It could turn out that many so-called auto-immune diseases are actually a byproduct of an immune system's battle with a virus. Lots more research needs to be done in that area. But many deaths from influenza are actually from an immune system's friendly fire.

The only viable protection is a vaccine that's well-matched to the virus. Reportedly anti-viral medications such as Tamiflu can "prevent" infection but only as long as they're taken on a prophylactic basis. Yet it's impractical, expensive, and maybe also unhealthy to take them for extended periods of time.

Frankly, given the way that Tamiflu works, I'm still unclear on whether it actually "prevents" infection or whether the drug kills off the virus before it can replicate after it's first invaded a cell.

(It's a matter for debate whether a virus is truly a life form but just as we speak of live and dead electrical wires, so we speak of live and dead viruses.)

Anyhow, exposing an immune system to a killed virus allows it to calmly develop antibodies at a leisurely pace.

As to vaccines that aren't well-matched: You'd think after all these millions of years of battling with bird influenzas the human immune system would recognize a flu virus in any guise, no matter how much it's mutated or recombined with other flu viruses. But the immune system is in some ways like a savant who can recognize hundreds of car makes and models but can never quite grasp the concept of "car."

That's why, year in and year out, vaccine makers have to collect that year's circulating flu strains and make a new vaccine that combines the strains, even though they've made similar vaccines so many times they can do it in their sleep.

What happens if a mutation that isn't in the cocktail becomes #1 on the influenza hit parade that year, after the vaccine has been made? You and the governments who paid for the vaccine are out of luck, that's what happens -- although if one of the strains in the vaccine is a close-enough match, your symptoms won't be as severe if you get infected with the virus.

But once you know that your immune system goes ballistic when it doesn't recognize an invading flu virus, you also know why you can stuff yourself with nutritional supplements and it won't make a bit of difference to that phenomenon.

Stop and think: would it make a difference to your reaction if you took adequate Vitamin D then found an armed stranger in your house? No? Then why would you expect your immune system to be as calm as a buddha in the same general circumstance just because you fed it Vitamin D?

Next question: Can good diet and mega-doses of certain nutritional supplements, medicinal herbs help in the recuperation process?

That's a question for a physician with a good grounding in nutritional medicine to answer. I do know from the readings I've done on the swine flu outbreak that what's crucial in the early stages of the disease are proper hydration and fast medical intervention.

Regarding your comments about vaccine: you can no more be poisoned from an influenza virus in a killed-virus vaccine than you can be electrocuted by a dead electrical wire.

It's impossible to get sick from being injected with an 'inactivated' or dead virus. So if you're sick after getting a flu shot, there are only four explanations:

Hysteria, suggestibility, allergy to eggs, or an allergic reaction to an additive in the vaccine. That last, beyond slight reddening and swelling at the shot site, is rare.

The jury is still out on whether the most famous illness associated with a flu vaccine, the Guillain-Barre Syndrome, actually came from the 1976 swine flu vaccine. And the biggest question is whether GBS arises as a reaction to the immune system going ballistic while it's fighting a virus it doesn't recognize.

Is it likely that the reports of GBS in 1976 were in some way connected with the vaccine? "Likely" is not a scientific term. Yeah, it seems likely from what we know at this point but Nature gives no quarter, no points for being half right.

As for the miniscule amount of mercury compound in the antibacterial additive in multi-dose flu vaccine vials: Just don't eat tuna fish for a few weeks before and after the shot if you're that worried about the cumulative effects of mercury in your body. And/or use a detox preparation, available at any health food store. Or demand a mercury-free vaccine injection.

As for children, who can be more sensitive to mercury compounds, there's the single-dose flu vaccine, which is free of the additive.

None of the above means I think flu vaccines carry no risks. Even the most stringent flu vaccine trials can't account for genetics; there can be rare reactions to flu vaccine but because they're rare they could show up only after hundreds of thousands of people, or even millions, received the vaccine; even then it that might take years before the harm became evident.

The other side of the risk coin is the long-term harm that can be done by the body's war with a virus.

Nor do I feel comfortable giving an opinion on MedImmune's live-virus nasal spray vaccine, the flu vaccines made from cell technology, or flu vaccines that use adjuvant.

I do have one question I haven't had time to research. Are any of the swine flu vaccines the U.S. government has purchased made from cell technology instead of the egg-based method?

The vaccine trials in the USA are testing swine flu vaccines from five different companies. Once testing is finished the U.S. government wants the FDA to fast-track approval for all the swine flu vaccines; this, on the argument that 2009 swine flu vaccines from all five companies are the same as the regular seasonal influenza vaccines made from egg culturing.

The argument wouldn't necessarily be true if any of the vaccines were made from cell technology; such a swine flu vaccine, if it's the first such product from a cell-based technology, would be experimental. I think that would mean the vaccine would require more extensive testing than the tried-and-true egg-based seasonal flu vaccines.

I know that the government is anxious to distribute as much swine flu vaccine as possible, as quickly as possible. But anxiousness is not a scientific method. Neither is fear.

There is no question that most governments have put too much faith in a vaccine. Even as early as June, governments that had contracted for swine flu vaccine were warned by vaccine makers that there was great difficulty growing the seed stock for the vaccine. Yet the governments continued to stick their heads in the sand -- assuring the public, even as late as mid-July, that the first vaccine shipments would be on time.

A month later, the CDC had to admit in public that only a fraction of the swine flu vaccine for the U.S. would arrive by mid-October. Worse, it takes two months for flu vaccine to be fully effective -- something I didn't know until recently; I'd thought it was between three and six weeks for full effectiveness.

Worse, the hyperfocus on vaccine development caused the U.S. government (and most other governments) to neglect other areas of pandemic-defense planning, with consequences that are potentially disastrous.

In short, their vaccine totem betrayed its worshippers. Now they're up the creek with only prayer left to the religious and luck left to the rest. Yet this is not a problem of bureaucracy; China's approach to dealing with the 2009 swine flu pandemic has been a textbook illustration of how governments must treat a pandemic virus in this era. The Chinese who thought up the approach and executed it are civil servants -- and/or they're civil servants who had the wits to listen to those outside government who knew how to deal with the 2009 swine flu outbreak.

So this goes much deeper than a problem with government. This is decades of wrong thinking about the nature of pandemics, thinking that did not keep pace with the times. The thinking grew like barnacles over public health regimes from here to Timbuktu. Science is as much to blame in this as the civil servants who were asleep at the wheel.

I remember talking more than 30 years ago in Nepal with a Nepalese doctor, Western trained, who told me, "There are diseases in this part of the world that the West has never heard of."

That's right, but the first-world governments could not encompass the implications; they didn't confront what would happen if diseases they'd never heard of began jetting in overnight. That wasn't a concern in those days, when most air travel was between first-world countries.

The harbinger was AIDS. The index AIDS patient was a Haitian working in the Congo. How did a Haitian end up working in the Congo? It's a question we don't bother to ask today because globalization of the work force is so much a part of modern life.

After I started writing about swine flu I received a letter from an American who earnestly claimed that every "new" viral disease since AIDS had been a creation of military laboratories. The reader was blind to the fact that the "laboratory" is international airports perched in countries that have few paved roads.

China's government, which made every mistake in the book in their response to AIDS, SARS, and H5N1, learned the hard way how the era of fully globalized work forces and international air travel intersected with infectious disease transmission. Their battle plan against the 2009 swine flu virus reflects lessons learned -- lessons that the rest of the world's governments have yet to absorb.

A swine flu vaccine is part of China's battle plan. But the difference between the first-world's approach and China's is that first-world public health officials weren't tuned into the present era. They failed to take into account the speed with which a pandemic could strike in this era, and the lag time between the onset of a pandemic and the development and distribution of a pandemic-fighting vaccine.

It sounds insane but prior to the 2009 swine flu outbreak, the CDC truly believed they'd have weeks to prepare in the event of an outbreak of a pandemic virus. How did they come to this idea? Well, they reasoned thusly:

Their computer models told them that the next pandemic virus would be an aerosolized version of the H5N1 ("bird flu") virus, which their computer models also told them would arise in Asia. This virus would be so lethal and kill so many people straight out of the box that it would immediately announce its existence -- and the falling bodies would slow the progression of the disease, as the virus 'burned through' human clusters. Ergo, the CDC thought they had a few weeks to prepare before the Doomsday virus arrived on U.S. shores.

As we know, the next pandemic was nothing like the CDC imagined.

What happens next?

I once heard Les Brown, a famous motivational speaker, explain why troubles could pile up at just the time we're trying to advance ourselves. He said that when you experience a lot of turbulence in your life, think of how an airplane can experience turbulence as it climbs to a higher altitude.

They're going to teach societies that just as a war is not won through any single tactic, so even the most powerful pharmaceutical interventions are not enough to protect humanity -- especially in this era of deadly infectious diseases that can span the globe within hours.

That's what is coming next: a move to a higher level of knowledge. All the rest is just turbulence.

1) Procrustes at RBO informed me around 3 PM EDT that she'd deleted the comment by STOP THE VAX. That's good news. Somehow the comment had slipped past her.

Sunday, August 23

When the news broke on August 19, international health officials, including Dr Anthony S. Fauci, head of NIH's National Institute for Allergy and Infectious Diseases, were understandably cautious. China's Sinovac Biotech company had not released data to support their claim that their swine flu vaccine required only one dose to be effective, which made it impossible to evaluate the claim.

But by then all eyes were turned to China. With the same showmanship that marked the opening of the 2008 Olympics, China's government had orchestrated a drama that was to unfold during a three-day international symposium on swine flu beginning August 21 in Beijing.

Virtually every vaccine expert outside China had predicted tests on human volunteers would show that two doses of swine flu vaccine were required. Yet China's swine flu vaccine trials, which were using 13,000 volunteers, dwarfed others underway around the world. If Sinovac's claim held up to scrutiny the ramifications could hardly be overstated. Details of the test results were to be unveiled at the symposium.

The confab, formally named the International Scientific Symposium on Influenza A/H1N1 Pandemic Response and Preparedness, hosted by China's Ministry of Health with the support of the World Health Organization (WHO) and the Lancet, had nearly 1,000 attendees from 30 countries and regions.

The attendees were heavy hitters in the public health and infectious disease management communities: top scientists, vaccine developers, health ministers and senior public health officials including those from the CDC and ECDC.

After interminable speeches and panel discussions, finally came the news everyone was waiting for. Bloomberg's Jason Gale reported on August 22 (Update 2 report; visit the Bloomberg site for several topic links in the report and the 3rd update):

A single standard dose of vaccine may be adequate to protect most people against swine flu, according to preliminary research in China that suggests twice as many people as projected could have access to the pandemic shot.

An experimental swine flu shot induced a protective immune response in 85 percent of adults who received an initial dose at the same strength used in a seasonal flu vaccine, Xiaofeng Liang, director of the national immunization program at the Chinese Center for Disease Control and Prevention, told a meeting in Beijing today.

Health officials are awaiting more data from China, as well as studies overseas, to confirm the results.

Authorities in the U.S. and U.K. have predicted two shots would probably be required, a regimen that would halve the amount of vaccine available to immunize people before the Northern winter.

“This is very promising information, and if we are able to get an immunogenic response with one dose as opposed to two doses, this would be a very significant change in our expectations,” Keiji Fukuda, the World Health Organization’s assistant director-general of health security and environment, told the meeting.

“Up until now, most of us have been thinking that two doses would be necessary to develop an immunogenic response.”

Interim Results

The results are based on interim results from two of the 10 [Chinese] companies conducting studies in China on vaccines to fight the new H1N1 virus. The first of the 13,000 test subjects to receive an experimental shot were vaccinated on July 22 and none had a serious adverse reaction to it, Liang said.

Several vaccine types and strengths are being tested in seven provinces of China across four age groups in studies supervised by the country’s CDC, he said.

The trials are assessing the safety and effectiveness of at least three different vaccine strengths in single or two-dose programs and involving inoculations based on whole and split viral particles, he said.

The studies also looked at whether an aluminum-based chemical called an adjuvant boosted the body’s ability to produce infection-fighting antibodies.

Vaccines produced annually for seasonal flu combine 15 micrograms of antigen -- the protein that prompts the production of antibodies -- to fight each of the three most common influenza strains.

Liang said that a similar dose would be needed to protect most people against the pandemic strain.

“Adolescents and adults had a better response than children and the elderly,” he said. “Taking into consideration the safety, immunogenicity and the cost, a 15-microgram, split vaccine without adjuvant could be used for future vaccination.”

The report's third update includes this paragraph:

No data is available in children younger than 3, Liang said. A final decision on whether one or two doses will be required to provide protection across all age groups in China won’t be taken until all the data has been collected and analyzed, he said.

If that sounds like a climbdown we'll have to wait and see.

It could be devastating for the vaccine manufacturers outside China, and a great embarrassment for governments who contracted with those companies, if they can't replicate the success of China's vaccine. In that event they could spend the next two months or maybe the rest of this century quibbling with China's test results.

So would Beijing decide it's the better part of valor, or at least the better part of doing business in today's complicated world, to go along with the crowd in the event the other vaccine trials showed the need for two doses?

I don't think so because there are too many lives at stake, too much threat from economic dislocation in the face of a pandemic, and a great many Chinese to vaccinate. From the discussion in the report, it's more likely they'll carefully match the number of shots to the requirements of different categories of people.

Even with the vaccine's success, China won't be able to roll out any more than 65 million doses by the end of this year. Yet that means they've been highly motivated to produce an effective one-dose swine flu vaccine without the added expense of an adjuvant's bells and whistles.

With China's quality control problems in mind -- toxic sidewall, lead paint on dolls, tainted milk product, etc. -- you might be tempted to ask whether getting immunized with China's swine flu vaccine would also mean you glow in the dark.

Well, if it's any comfort, China's Health Minister, Chen Zhu, got his first swine flu jab on July 22 and a second shot on August 22 and he hasn't dropped dead yet or turned green. But I doubt China's 2009 swine flu vaccine will be much available outside the country.

WHO has been so impressed with China's effort they've delivered the ultimate compliment: mooching. When WHO hits you up for freebies on behalf of the world's neediest that's a sign you've arrived as a pharmaceutical supplier.

As to how any WHO official would have the gall to ask a developing country with more than a billion people to share any of its small vaccine supply during a pandemic -- I hope Beijing tactfully interprets the touch as a request that their vaccine companies focus on making flu vaccines for the world's basket-case countries.

As for the purity of the vaccine, Beijing has a lot to prove because of the quality control issues and their crummy health system, which WHO politely refers to as "spotty."

At the start of this year Beijing made it a national goal to develop a world-class health system and get into pharmaceutical development and manufacturing in a big way. That's a part of their economic stimulus plan. They are now heavily invested, both emotionally and financially, in making the best flu vaccines possible.

Friday, August 21

There has been bad news on the swine flu front since I last posted. On August 17 the CDC announced that the 120 million doses of swine flu vaccine they were expecting for delivery in mid-October had been chopped to 45 million doses.

I'll discuss the situation in more detail later in this post; for now, the delay in vaccine deliveries means that the regular flu season in the USA will be in high gear by the time the nation's schoolchildren are vaccinated against swine flu in appreciable measure. If the flu season is marked by a high incidence of swine flu infections, the choices facing parents and school administrators are very narrow.

I won't sugar-coat this: the ship left the pier in March when the CDC initially made the wrong call on how to handle the swine flu outbreak. Since then the choices have gotten increasingly unpalatable.

The American public, including school administrators, was never explicitly told certain things about the 2009 swine flu viral infections. The information missing from the nightly news was out there, on the internet, and I've discussed in on my blog. But it was not until the 21st (Singapore time) that a mainstream reporter, Bloomberg's Jason Gale, pulled together many bits of data to deliver a bleak picture of the swine flu outbreak:

Yes, the death toll from swine flu is relatively low, although I stress that "relatively" in this context is a matter for heated debate. But the catch is the way the 2009 swine flu attacks those who become seriously ill with the infection:

In some patients, the virus causes such a severe assault on the respiratory tract that the lungs become inflamed and the grape-like sacs where gas is exchanged are injured, causing bleeding and a critical loss of oxygen supply.(1)

Jason's report details that saving those patient's lives, which can require highly specialized procedures and keeping them on lung ventilators for weeks, means hospitals must make triage decisions. During a large swine flu outbreak the decisions will mean that people with other serious illnesses can die for want of hospital care.

So what are Americans facing, as the school year and flu season get underway? From one of the most quoted American authorities on the 2009 swine flu outbreak:

“The Northern Hemisphere medical care requirements for the next six months are a train wreck waiting to happen,” said Michael Osterholm, director of the University of Minnesota’s Center for Infectious Disease Research and Policy in Minneapolis. “In the fall, even if nothing else changes in terms of the virus’s severity and our preparedness, it’s going to be a real challenge.”(1)

From that perspective the CDC's updated guidelines to schools develop even greater importance than when they were published on August 7. Now to take up where I left off in the last post:

This post addresses the CDC's guidelines to U.S. schools on the use of non-medical or 'non-pharmacological' interventions (NPIs) to mitigate the effects of a swine flu outbreak in a school while keeping the school open.

My analysis is based on information in the CDC's online handbook, Technical Report for State and Local Public Health Officials and School Administrators on CDC Guidance for School (K-12) Responses to Influenza during the 2009-2010 School Year.

I note that the technical report links to a "technical handbook" that contains URL hyperlinks to various NPI topics addressed in the report, which resolves my earlier complaint about the report's dearth of hyperlinks.

My first post on the guidelines addressed screening for swine flu symptoms and the use of isolation rooms; the second one the length of time students/staff who'd recovered from flu should refrain from returning to school.

In both posts I observed that the CDC advice on every topic I'd covered was inadequate. It's as if, after announcing that they believed vaccination was the most effective means for combating influenza, they added NPIs merely to placate parents and school staff who demanded information on them.

If you tell me after reading the Canadian guidelines that many high school girls would refuse to forego artificial nails and nail polish -- this is the tiresome thing about pathogens: they don't give humans an A for a college try. Hand washing with regular soap doesn't 'kill' or neutralize pathogens; it rolls or washes them off the hands (something the CDC guidelines don't mention). So if nail polish is chipped the bugs can lodge in the cracks and thus avoid going over Niagara Falls. The same principle applies if the person doesn't scrub underneath long nails.

Anti-microbial soaps are better for schoolchildren provided the soaps are used properly -- washing at least 20 seconds (I think 30 seconds is better) and getting the soap under the nails.

The same with the anti-microbial gels. While some alcohol-based gels promise on their label to kill germs within 15 seconds of application I'd have to see the studies before I'd accept the claim. Recently I spent an evening in email conversation with a science researcher on the matter of exactly what strength ethyl alcohol should be used to kill pathogens and how long it takes for the alcohol to work. He told me that 70% solution is very effective and that it kills within 30 seconds.

It could be the popular 2 fluid oz. gel bottles can get away with a 62% solution because the alcohol is more concentrated in a small bottle. But until one of us can investigate further I'd stay on the safe side of waiting 30 seconds before assuming the stuff had worked.

A study has shown that people touch their face on average of 200 times a day; if you have the swine flu virus on your hands then rub your eyes or touch your mouth -- congratulations; you've given yourself the flu! From that perspective, be willing to spend an extra 10 or 15 seconds washing your hands properly when you're in a flu outbreak region.

I saw a television segment in which a school administrator in Georgia state proudly showed off large Purell anti-microbial gel dispensers that were placed in her school's halls. That's a great idea -- particularly because an easy way for students to become unpopular is if they hog a bathroom sink for a full 30 seconds of hand washing during the lunch break. But again, the little darlings need to be taught to get the gel under their nails and keep their nails clipped short.

Moving to the CDC guidelines on cleaning surfaces, this is one of the most troubling pieces of advice for schools wishing to deploy NPIs against swine flu:

The American Academy of Pediatrics provides guidance for school cleaning and sanitizing which is appropriate for influenza. Schools should regularly clean all areas and items that are more likely to have frequent hand contact (for example, keyboards or desks) and also clean these areas immediately when visibly soiled. Use the cleaning agents that are usually used in these areas.

Some states and localities have laws and regulations mandating specific cleaning products be used in schools. School officials should contact their state health department or department of environmental protection for additional guidance.

Schools should ensure that custodial staff and others (such as classroom teachers) who use cleaners or disinfectants read and understand all instruction labels and understand safe and appropriate use. Instructional materials and training should be provided in languages other than English as locally appropriate. CDC does not believe any additional disinfection of environmental surfaces beyond the recommended routine cleaning is required.

See the American Academy of Pediatrics’ Managing Infectious Diseases in Child Care and Schools: A Quick Reference Guide, 2nd Edition (2009) for guidance on cleaning and sanitizing in schools.

The EPA provides a list of EPA-registered products effective against flu.

That's it; that's all the CDC school guidelines have to say on the matter of cleaning, which means they omit discussion of how long pathogens can survive on surfaces. The link to the AAP quick reference guide is simply to a page with information on how to purchase the guide so I don't know whether the guide discusses the issue.

I assume that all U.S. schools have guidance from somewhere on the issue; however, it doesn't make sense for the CDC school guidelines to omit data on the crucial question of how long pathogens stay on surfaces -- particularly because there's a big discrepancy between data they cite elsewhere on their website and that from other sources. Here is what the CDC has to say on the topic at their H1N1 Flu and You Q&A page under the subheader Contamination and Cleaning:

How long can influenza virus remain viable on objects (such as books and doorknobs)?

Studies have shown that influenza virus can survive on environmental surfaces and can infect a person for 2 to 8 hours after being deposited on the surface.

Clearly other studies have a far different story to tell. During her radio interview with John Batchelor in July, Filligent CEO Melissa Mowbray-D'Arbela said that pathogens can live for "a day or a day and a half" on surfaces.

The length of time that cold or flu germs can survive outside the body on an environmental surface, such as a doorknob, varies greatly. But the suspected range is from a few seconds to 48 hours — depending on the specific virus and the type of surface.

Flu viruses tend to live longer on surfaces than cold viruses do. Also, it's generally believed that cold and flu viruses live longer on nonporous surfaces — such as plastic, metal or wood — than they do on porous surfaces — such as fabrics, skin or paper.

Although cold and flu viruses primarily spread from person-to-person contact, you can also become infected from contact with contaminated surfaces. The best way to avoid becoming infected with a cold or flu is to wash your hands frequently with soap and water or with an alcohol-based sanitizer.

Because Filligent scientists earn their living in a for-profit environment and thus, can't afford to get many facts wrong, I'd advise school administrators to assume the swine flu virus can live on surfaces for at least 36 hours.

If administrators in schools that saw swine flu outbreaks this Spring were following the 2-8 hour estimate put out by the CDC, it's possible they assumed they could get by with cleaning the most obvious 'touchable' surfaces, such as chairs and desks, and that the daily overnight closing of the school would take care of the rest of the viruses. If that's how they were thinking it's no wonder it was so hard to tamp down an outbreak in the schools.

Again, viruses don't grade humans for sincere efforts. I am reminded of a macabre but very telling joke that a guest on John Batchelor's show related during the SARS outbreak in China, which initially was traced to a military hospital:

"Looks as if the janitor missed cleaning a doorknob at the hospital."

Just because the school surface isn't touched often, if it's touched by any student and it has 'live' swine flu virus on it, bingo! it's being spread around the school faster than you can say hiss cat with every additional surface the student touches.

What's the solution, then? Given how hard it is to tamp down an airborne virus, isn't the CDC right to emphasize that a vaccine is the best defense against swine flu? If the vaccine is available and it's well-matched to the virus, yes. However, as I mentioned earlier, there's been a glitch with the swine flu vaccine delivery for the USA.

For months CDC assured the public and school administrators that the first delivery of swine flu vaccine, scheduled for mid-October, would be 120 million doses. On August 17 they announced that the October delivery would only be 45 million doses.

Figure half that amount if the human vaccine trials, which are still underway, determine it'll take two doses of vaccine to provide adequate protection. Right now the public health community is betting that two doses will be needed.

It's not a shortage but a delay, Health and Human Services spokesman Bill Hall said. More will arrive rapidly after that, with about 20 million more doses being shipped weekly until the government reaches the full 195 million doses ordered, he said.

But the October shortfall, blamed on manufacturing issues, will extend by a month efforts to get people at highest risk vaccinated against the new flu strain. First in line are supposed to be pregnant women, children and health care workers, followed by younger adults with flu-risky conditions such as asthma.

Expect vaccination campaigns to start around Oct. 15 anyway, Hall said. They just will have to be smaller in scale than originally planned, as the supply trickles in more slowly.

"Why would we wait? As vaccine comes in, we'll ship it out to the states. We're not going to sit on it," Hall said.[...]

Yes, well, that's not the biggest issue. There are between 53 and 55 million children and 7 million staff at U.S. schools. The CDC - HHS updated recommendation on August 7 that schools open on time in September and stay open, even during a swine flu outbreak, was based on their rosy prediction that large-scale vaccinations of schoolchildren would begin in mid-October.

I bought into the prediction because I assumed the CDC wouldn't be so stupid as to make the recommendation without being certain that the first shipment of vaccine would be 120 million doses. That's why I suggested in an earlier post that U.S. schools in regions with swine flu outbreaks delay opening until vaccine had been administered in mid-October.

Keep in mind that it takes three to six weeks for a vaccine to reach full effectiveness, with three weeks the time used in the NIH-funded human vaccine trials to discover whether one or two doses of vaccine are needed.

The delay in the vaccine program changes everything. So I suggest that parents, school administrators, and public health officials read Jason Gale's report with great care, then revisit their thinking about the best course for handling a swine flu outbreak in schools. If they are determined to open the schools on time and keep them open during swine flu outbreaks, that leaves NPIs to bridge the gap until the vaccine program is well underway.

The NPI route is very hard, very labor intensive. And as you can see from all the above, a highly infectious virus allows humans little room for error when they're closely grouped. This doesn't mean NPIs shouldn't be used in abundance in the schools; on the contrary. Secondary infections can be a bigger killer than a virus during a pandemic.

The NPIs, if done right, will greatly reduce germs of all kinds, including bacteria that exacerbate viral outbreaks in schools. However, the emphasis is on "done right." So another thing the CDC can do is clean up the errors, omissions, and contradictions I've noted in this three-part series on their NPI guidelines.

Saturday, August 15

This entry picks up from the Wednesday one, which addressed the CDC's updated guidelines to U.S. schools for the deployment of non-medical or 'non-pharmacological' interventions (NPIs) to mitigate the effects of swine flu outbreak in a school while keeping the school open.

My analysis is based on information in the CDC's online handbook, Technical Report for State and Local Public Health Officials and School Administrators on CDC Guidance for School (K-12) Responses to Influenza during the 2009-2010 School Year, a version of which will be published on August 23 for colleges and offices.

Unfortunately the handbook's headers and subheaders are not hyperlinked, which means a hunt if you want to check out the specific topics I reference, but in general the guidelines are divided into two broad categories:

"Recommended responses under conditions with similar severity as in spring 2009"

"Recommended additional responses during times of increased influenza severity"

The handbook doesn't elaborate on what is meant by "severity" in either case, which leaves open whether the CDC is referring to the size of flu outbreaks in schools or the lethality of a virus.

But from various discussions in the handbook I'd guess "severity" in this context refers to the size of outbreaks; this, on the supposition that if a more lethal strain of flu appears in the USA during the upcoming school year, the CDC would advise that schools close, whether or not students had been vaccinated.

The CDC's advice to schools about the use of NPIs is clearly based on their opinion that most swine flu infections are mild. In the earlier post I addressed two of the handbook's NPI recommendations:

1) "infection symptom screening of students and staff when they arrive at school," which pertains to a more severe outbreak.

2) schools should set up a 'quarantine' or isolation room for sick staff and students until they can be transported off the premises.

The second recommendation applies to both types of severity.

To review: I found the advice about a screening process to be inadequate -- so inadequate that it was clearly intended only to identify, in the most haphazard fashion, an ill student or staff person in the school. In other words, the advice steered clear of the use of screening measures for the purpose of limiting the spread of a swine flu outbreak in the school.

That makes sense because if the CDC ever recommended the kind of screening measures that are actually intended to slow the rate of an airborne viral infection in a school or anywhere else, their entire argument against the use of such screening measures at a country's ports of entry would collapse.

That must not happen. At all costs the sun must continue to circle the earth; to admit to the opposite would destroy the ancien regime defended by the CDC, WHO, and every other guardian of public health that considers China's approach to fighting swine flu to be apostasy.

With those sarcasms off my chest, the recommendation about an isolation room was so poorly thought out that if not backed by additional strategies, it could pose mortal danger to students who were seriously ill at school with swine flu. An isolation room should only apply in combination with rapid medical intervention, which is not possible in schools without a physician on duty.

Of course ill students should be immediately separated from others in the school. But when school administrators plan for a swine flu outbreak the emphasis should be on transporting the student to a medical facility, in the event a parent or guardian is unable to get the child to a doctor within an hour of notification by the school.

Now we move to the CDC's advice on how long a recuperating student should remain out of school. During the Spring swine flu outbreak the CDC recommended at least seven days after fever had subsided. This recommendation has been chopped down to "at least" 24 hours:

Stay home when sick

CDC recommends that individuals with influenza-like illness remain at home until at least 24 hours after they are free of fever (100° F [37.8° C] or greater), or signs of a fever, without the use of fever-reducing medications.

This recommendation is based on epidemiologic data about the overall risk of severe illness and death and attempts to balance the risks of severe illness from influenza and the potential benefits of decreasing transmission through the exclusion of ill persons with the goal of minimizing social disruption.

[...]

Many people with influenza illness will continue shedding influenza virus 24 hours after their fevers go away, but at lower levels than during their fever. Shedding of influenza virus, as detected in laboratory tests, can be detected for 10 days or more in some cases. Therefore, when people who have had influenza-like illness return to school they should continue to practice good respiratory etiquette and hand hygiene when they return to school and avoid close contact with people they know to be at increased risk of influenza-related complications.

[...]

The CDC returns to seven days for outbreaks of greater severity than the Spring one:

Extended exclusion period

If influenza severity increases, individuals with influenza-like illness should remain at home for at least 7 days, even if symptoms resolve sooner. Individuals who are still sick 7 days after they become ill should continue to stay home until at least 24 hours after symptoms have resolved.

This recommendation is based on viral shedding information. Influenza virus shedding general [sic] occurs for 5 to 7 days for seasonal influenza infection. This period may be longer for persons with 2009 H1N1 flu and among young children and people who are immunocompromised.

[...]

If you observe that the second discussion of virus shedding doesn't quite comport with the first one -- it does seem they've switched horses mid-stream, doesn't it?

The first discussion of virus shedding pertains only to "influenza-like" illness. The second discussion specifically mentions the "2009 H1N1" [swine flu] virus. But now re-read the title of the manual. The guidelines pertain to "influenza" not specifically to the 2009 swine flu outbreak.

Those readers who closely followed news reports on the CDC's "new" guidelines for schools, which emphasized the "new" 24-guideline, might be slapping their forehead by this time. Yeah, the CDC palmed an ace from the bottom of the deck.

Remember, the objective is to keep the schools open this autumn and minimize "social disruption" even during a major swine flu outbreak.

For all I know the CDC has been cranking out the same influenza manual for decades, and only made a few changes to accommodate the 2009 swine flu outbreak. In any event, for schools trying to prepare for swine flu outbreaks, the second discussion about viral shedding overturns the first one, even though it's qualified ("may be longer") because only the second one specifically mentions swine flu.

That means parents and school administrators would be wise to stick with the seven-day guideline and forget the 24-hour one, unless the sick child is tested and found to have a garden-variety flu.

What's more the CDC's argument about viral shedding is irrational, if we're to assume that by "severity" of an influenza outbreak the CDC means its size rather than increased lethality, or any other significant mutation of the virus that might possibly affect viral shedding.

Of course the larger the outbreak, the more chance for larger numbers of seriously ill people and more deaths. But whether 10 people or 1,000 contract a particular virus has no bearing on how long they shed the virus.

All right. That's all my delicate nerves can stand of the CDC's logic for one day. Next I'll tackle the guidelines on hand washing and cleaning of school surfaces.

Friday, August 14

At town hall meetings across the country Imperial Washington has been put on notice: The American middle class won't stand still while health care reform is rammed down their throats.

But this is only round one. Obama's courtiers and supporters in various health-related industries are gearing up for counter-strikes that will include flooding the TV airwaves with advertising in support of Obama's health reform plan.

The first assault, funded largely by the properly terrorized U.S. pharmaceutical industry (which, with help from Ted Kennedy's vote, has for the moment dodged Congress' seven-year bullet regarding the expiration of propriety research on patented drugs), is a $12 million television ad campaign to support of the Democrats' health reform plan.

See Politico for details, which include the news that the first ads are only the shock troops in advance of the TV blitzkrieg this autumn.

At his blog John Batchelor quotes the text of the new ad and observes, "The script is bland, aimless, repetitive, colorless, dull and timeless."

There is one part of the soothing ad, however, that can easily slip past the uninformed -- the part that explains the reform plan includes a "focus on preventing illness before it strikes."

On paper that sounds like a great idea. However, Charles Krauthammer (who has a medical degree, as do all psychiatrists) has shredded the argument that a publicly funded preventive medicine program will greatly reduce health care costs; indeed, the program will do just the opposite:

WASHINGTON August 13 -- In the 48 hours of June 15-16, President Obama lost the health-care debate. First, a letter from the Congressional Budget Office to Sen. Edward Kennedy reported that his health committee's reform bill would add $1 trillion in debt over the next decade. Then the CBO reported that the other Senate bill, being written by the Finance Committee, would add $1.6 trillion.

The central contradiction of Obamacare was fatally exposed: From his first address to Congress, Obama insisted on the dire need for restructuring the health-care system because out-of-control costs were bankrupting the Treasury and wrecking the U.S. economy -- yet the Democrats' plans would make the problem worse.

Accordingly, Democrats have trotted out various tax proposals to close the gap. Obama's idea of limits on charitable and mortgage-interest deductions went nowhere. As did the House's income tax surcharge on millionaires. And Obama dare not tax employer-provided health insurance because of his campaign pledge of no middle-class tax hikes.

Desperation time. What do you do? Sprinkle fairy dust on every health-care plan, and present your deus ex machina: prevention.

Free mammograms and diabetes tests and checkups for all, promise Democratic leaders Nancy Pelosi and Steny Hoyer, writing in USA Today. Prevention, they assure us, will not just make us healthier, it also "will save money."

Obama followed suit in his Tuesday New Hampshire town hall, touting prevention as amazingly dual-purpose: "It saves lives. It also saves money."

Reform proponents repeat this like a mantra. Because it seems so intuitive, it has become conventional wisdom. But like most conventional wisdom, it is wrong. Overall, preventive care increases medical costs.

This inconvenient truth comes, once again, from the CBO. In an Aug. 7 letter to Rep. Nathan Deal, CBO Director Doug Elmendorf writes: "Researchers who have examined the effects of preventive care generally find that the added costs of widespread use of preventive services tend to exceed the savings from averted illness."

How can that be? If you prevent somebody from getting a heart attack, aren't you necessarily saving money? The fallacy here is confusing the individual with society. For the individual, catching something early generally reduces later spending for that condition.

But, explains Elmendorf, we don't know in advance which patients are going to develop costly illnesses. To avert one case, "it is usually necessary to provide preventive care to many patients, most of whom would not have suffered that illness anyway." And this costs society money that would not have been spent otherwise.

Think of it this way. Assume that a screening test for disease X costs $500 and finding it early averts $10,000 of costly treatment at a later stage. Are you saving money? Well, if one in 10 of those who are screened tests positive, society is saving $5,000. But if only one in 100 would get that disease, society is shelling out $40,000 more than it would without the preventive care.

That's a hypothetical case. What's the real-life actuality in the United States today? A study in the journal Circulation found that for cardiovascular diseases and diabetes, "if all the recommended prevention activities were applied with 100 percent success," the prevention would cost almost 10 times as much as the savings, increasing the country's total medical bill by 162 percent.

Elmendorf additionally cites a definitive assessment in the New England Journal of Medicine that reviewed hundreds of studies on preventive care and found that more than 80 percent of preventive measures added to medical costs.

This doesn't mean we shouldn't be preventing illness. Of course we should. But in medicine, as in life, there is no free lunch. The idea that prevention is somehow intrinsically economically different from treatment -- that treatment increases costs and prevention lowers them -- is simply nonsense.

Prevention is a wondrous good, but in the aggregate it costs society money. Nothing wrong with that. That's the whole premise of medicine:

Treating a heart attack or setting a broken leg also costs society. But we do it because it alleviates human suffering. Preventing a heart attack with statins or breast cancer with mammograms is costly. But we do it because it reduces human suffering.

However, prevention is not, as so widely advertised, healing on the cheap. It is not the magic bullet for health care costs.

You will hear some variation of that claim a 100 times in the coming health-care debate. Whenever you do, remember: It's nonsense -- empirically demonstrable and CBO-certified.

I add that Krauthammer had the good grace on to admit on a Fox panel this week that his first assessment of the impact of the town protests had not been borne out by events.

Last Friday on the Fox panel he'd said that the protestors at the town hall meetings had carried themselves so badly that the Obama administration had won the week.

Krauthammer observed that polling has shown just the opposite: many Americans became engaged in the debate during the past week when they learned about the protests, and then turned out at the town hall meetings to add their voices.

The upshot is that the Obama Team's strategy to characterize the protestors as a right-wing fringe segment directed by Republican operatives has collapsed, leaving egg on the team's collective face.

But this is no time for victory celebrations; this is the time to hunker down. Obama's team is determined to provide him with a 'win' on his health care reform proposal, and hang the cost to the taypayers.

So from here on out, it's not enough for middle America to raise hell. The Obama wing of the U.S. media will keep the focus on the drama of the protests. That will make it hard for the general public to get the information they need to debate the particulars of the health care bill proposals in the House and Senate.

And make no mistake: the Bread & Circus approach to winning support for poorly-constructed, wasteful legislation is tried and true in Washington.

Wednesday, August 12

On Friday the U.S. departments of homeland security, education, heath and human services (HHS), and the CDC (Centers for Disease Control and Prevention), issued a joint announcement on the updated guidelines regarding whether U.S. schools should remain open during an outbreak of swine flu.

As I detailed in my Monday post the guidelines were spun two ways: one way for the unwashed masses and another way for education and public health authorities at the state/local levels.

The message to the public, delivered via a phone presser for the news media and a joint televised press conference, emphasized that schools should remain open in the event of a swine flu outbreak in the school, and by implication that schools should open on time this year.

The recommendation was qualified by the observation that if so many students and staff were sick from swine flu, or if parents of sick children kept sending them to school, schools should close in the those events. However, Thomas Frieden, the CDC director, spelled out for the public the government's overriding message: “It’s now clear that closure of schools is rarely indicated, even if H1N1 is in the school.” (1)

The published version of the guidelines, which is directed at state and local education officials via the CDC and HHS web sites, is neutral on the question of whether schools should open on time this year and close during a swine flu outbreak in a school. (For readers outside the USA: local authorities, not the federal government, have jurisdiction on the matter of school closings.)

However, the guidelines include a handful of non-medical strategies (or 'non-pharmacological interventions' - NPIs -- as they're called in the trade) that school officials could deploy to mitigate the effects of a swine flu outbreak among students while keeping the school open.

The strategies are extensively supplemented in the CDC's handbook, Technical Report for State and Local Public Health Officials and School Administrators on CDC Guidance for School (K-12) Responses to Influenza during the 2009-2010 School Year. A version of the federal guidelines and handbook will be published on August 23 for colleges and offices.

If it seems the CDC advice is coming a little late in the day, it's coming four months late in the day, to be precise -- almost four months to the day the government got around to announcing the swine flu outbreak. If one really wanted to nitpick, the advice is coming four years late in the day; that would be four years after the government issued their vague and incomplete pandemic planning manual. But there I go again, harping on details.

Be happy that the CDC is now a veritable fountainhead of advice on how schools can deal with a pandemic virus while remaining open. The catch is that much of the advice ranges from inadequate to pretty damn strange.

In truth the CDC remains firmly wedded to their belief that vaccination is the "best way" to prevent the spread of swine influenza.(1) Those impertinent enough to ask them, 'Wouldn't deploying NPIs until the vaccine is distributed actually be the best way?' are looked at as if they've farted.

Nonetheless, in what could be a token gesture to Americans such as Pundita, who keep pestering them with annoying questions (How come Mainland China's death toll from swine flu is zero and America's is 436? Huh? Huh? How come America doesn't have a pandemic-fighting plan like China's, huh? huh? When are we going to get airport screening measures like Mainland China's, huh?), the CDC has graciously included the suggestion in their handbook that schools deploy screening measures in the event that the swine flu outbreak becomes "severe." Under the sub-header "Active screening for illness" the CDC writes:

If influenza severity increases, schools should consider instituting active fever and respiratory infection symptom screening of students and staff when they arrive at school. At the beginning of the school day, all students and staff should be asked about suggestive symptoms such as fever, cough, runny nose, and sore throat during the previous 24 hours. Some persons with laboratory-confirmed influenza do not have a fever (between 10% and 40% of people). Therefore, absence of fever does not indicate absence of infection.

In a higher severity situation, schools should send home persons with symptoms of acute respiratory infection (that is, any two of the following: sore throat, cough, runny nose [new and unexplained by allergies], or fever). As always, parents should be aware of their child’s health status and monitor them for illness every morning before school.

Throughout the day, staff should be vigilant in identifying students and other staff who appear ill. These students and staff should be further screened by the school nurse, or other school-based health care worker, by taking their temperature and inquiring further about symptoms. Students and staff who develop symptoms of acute respiratory infection at school should be separated from others until sent home. When possible and if the sick person can tolerate it, he or she should wear a surgical mask until sent home.

Straight out of the gate we come to a snag. I forget which of the two ferret studies (Netherlands, CDC) that were published a couple months ago mentioned a finding about the attack range of the swine flu virus. But physician DocJim posted the information in one of my comment sections with a note on the attack range, which if I recall correctly is two meters.

That's just for infection that can be transmitted through normal breathing; for sneezes and coughs the CDC handbook recommends keeping a distance of six feet -- and indeed it cites the six-foot distance as the safe one for avoiding contamination from infected people under all circumstances.

That presents a problem for health workers who would be tasked with taking students' temperatures during a swine flu outbreak in the school.

Remember the photographs of Chinese health workers garbed in biosafety suits while they were taking temperatures of arriving international passengers? Those aren't hazmat suits with their own air supply but the disposable uniforms cover the worker head to toe, and are finished off with safety goggles and respirator-style face masks.

That get-up is the only certain way to avoid exposure to the highly infectious airborne swine flu virus if you're standing closer than six feet to an infected person. Just slapping on an ordinary, ill-fitting surgical paper mask -- none of which are designed to stop a virus, anyhow -- is a token gesture, particularly if goggles aren't worn.

Note the CDC advice does not mention biosafety suits or goggles, and it leaves unaddressed the vexing problem of how to take a student's temperature from a distance of six feet. Maybe the infrared temperature guns will work at that distance, although I wouldn't bank on it and in any case I doubt many U.S. schools are equipped with them.

In any event, the CDC handbook does not provide a discussion of how the school health worker avoids infection while taking the temperature of a student who seems ill with swine flu.

Nor does the handbook admit to the obvious, which is that taking temperatures of students after they enter the school is another token gesture that undercuts the rationale for screening.

Not to keep throwing China in the CDC's face, but in Mainland China many corporations have chosen to make their contribution to battling swine flu by lining up their employees and taking their temperature before they enter the office for the work day.

No, the employees don't mind; they're proud of their contribution to keeping China's swine flu cases low. Amazing but true good citizens rather enjoy chipping in during a national crisis without waiting on government to tell them what to do. We saw that in the USA on 9/11 and the weeks that followed, and again during Hurricane Katrina's aftermath.

However, it would be a logistical nightmare to line up students outside, in a large school, to have their temperatures taken before they entered the building at the start of the school day. Of course there are workarounds; e.g., staggered student arrival times.

But in short if you want to do school screenings right, and not just make them a token gesture, it takes more planning and effort than the CDC handbook indicates.

Moving downhill from there, schools are looking at another logistical nightmare if they follow the CDC's advice to send infected children home. And their municipalities are facing the possibility of a large number of law suits, if sick children who are sent home without adult supervision become seriously ill or die.(2)

One of the government's biggest rationales for keeping schools open during a swine flu outbreak is that many working parents can't afford day care while their children are kept out of school. This is a particular concern for single working mothers at the lowest end of the economic scale.

Okay, but the snag is that if there's an outbreak in the school and children have to be sent home in droves, or the outbreak is so large the school has to close, this will mean parents having to take off work with no notice and stay at home to look after their sick children for what could be several days.

The CDC handbook's attempted workaround is another snag. They suggest that schools set up a "quarantine" or isolation room, where sick children can wait for their parents to pick them up.

But if the student is ill enough to require medical attention his waiting for hours in an isolation room, until a parent can get to the school to pick him up, could mean a critical delay in medical intervention. Many U.S. public schools don't even have a nurse on duty, much less a physician.

And realize that during a large swine flu outbreak in a school's region, the emergency rooms there are going to be swamped. This is a huge concern right now for U.S. medical authorities, who are bracing for a renewed onslaught of swine flu in the autumn.

Yes, delaying the opening of schools until the swine flu vaccine can be administered, or closing schools during an outbreak, is a hardship for parents who depend on the schools to babysit.

But if HHS had warned parents at the beginning of the pandemic that they should expect school openings to be delayed in the autumn by as much as two months, parents would have had four months to work out a plan to deal with the problem.

That would have given them time to contact relatives and ask for their help in looking after their children during parental work hours. It would have given religious organizations, community leaders, and the schools time to help parents deal with the problem.

Yet now, at the Eleventh Hour, there's little time for planning. And parents must face the prospect of unannounced school closings due to a large outbreak in their children's school.

Moving further downhill in the CDC's handbook of NPI suggestions -- but I think that's enough bad news for one day. I'll pick up from here in the next post, which will be on Friday at 7:00 AM EDT.

1) The New York Times: Swine Flu Should Not Close Most Schools, Federal Officials Say ; Denise Grady; August 7, 2009

2) The New York Times: First Flu Victim’s Family Intends to Sue City; ANEMONA HARTOCOLLIS; August 12, 2009

If state health projections hold true, some 160 Lee County residents and 5,000 Floridians will die from the A/H1N1 flu in the next 18 months to two years, the average life cycle of a pandemic, said Jennifer James-Mesloh, the Lee County Health Department spokeswoman.

That's twice as many deaths as Lee County sees in a typical flu season, she added.

[...]

The rapid increase of fatalities from the A/H1N1 virus seems unpredicted by the health officials and local citizens in the state.

The U.S. federal government sent different messages on Friday on the matter of whether schools should close during a swine flu outbreak.

They sent one message in a CDC phone presser for the news media on Friday morning and followed this with a joint news conference at HHS that included Kathleen Sebelius and the heads of Homeland Security, Education and the CDC.

The message: Based on CDC guidance, the federal government advises against school closings even if there is an outbreak of swine flu in the school.

All the major press outlets dutifully passed along the message to the public, which was also broadcast on the nightly TV news on Friday. The message was unequivocal:

"It's now clear closure of schools is rarely indicated," said Thomas R. Frieden, the director of the Centers for Disease Control and Prevention.

And as I noted above HHS Secretary Kathleen Sebelius chimed in with, "What we are seeing looks very much like seasonal flu so far."

However, the HHS and CDC web sites had a different message. The identical press releases posted at the sites on Friday made no mention of any federal advice to keep schools open during a swine flu outbreak or to open schools on time even in the face of an epidemic. From the first paragraph of the press release, which is titled:

Updated federal guidelines offer state and local public health and school officials a range of options for responding to 2009 H1N1 influenza in schools, depending on how severe the flu may be in their communities. The guidance says officials should balance the risk of flu in their communities with the disruption that school dismissals will cause in education and the wider community.

The press release continues in that vein, with Education Secretary Arne Duncan chipping in, “We can all work to keep our children healthy now by practicing prevention, close monitoring, and using common sense. We hope no schools have to close. But if they do, we need to make sure that children keep learning."

Offering a range of options is a far cry from issuing a guideline that schools should stay open even during a swine flu outbreak.

Now why did the CDC-HHS send a different message on their web sites than the one they projected at press conferences?

The answer would be matter of conjecture.

The message at the CDC - HHS web sites, which is an official federal update, gets emailed to state and local health and education authorities.

From that, I'd say it's likely the first message was directed at the public, whereas the message on the web sites was directed at school and public health administrators.

The feds have no jurisdiction in the matter of school closings, even though state and local health/education officials take their guidance from CDC scientists when it comes to infectious disease control at school. The most the feds can do is make their opinion known to the school administrators.

So why didn't their written update contain a strongly-worded recommendation that schools remain open even when experiencing an outbreak of swine flu?

Again, the answer would speculative. The education department and HHS clearly want the schools to remain open and to open on time. Setting aside their rationale that closing schools and delaying their opening would be socially disruptive, there is a logistical reason for their decision:

Earlier in the year the CDC and HHS flogged the vaccine manufacturers to have their regular seasonal influenza ready in record time so the companies could start work on the swine flu vaccine.

The CDC's plan was to get schoolchildren vaccinated with the seasonal flu vaccine in August-September through a vaccination program at the schools. However, at that time the CDC was assuming swine flu would act like the regular seasonal flu and leave the Northern Hemisphere for a few months. That didn't happen.

So now there are millions of doses of seasonal flu vaccine ready for distribution at the schools as soon as the schools open. But because the swine flu outbreak is going full tilt in several U.S. states, as soon as millions of kids show up at school, this is expected to touch off large swine flu outbreaks. That situation has already happened at one school that is open this early in the year. It might have been a school in North Carolina although don't hold me to the name of the state. In any event the school had to close immediately.

Without shutting the schools, the projected outbreaks this autumn would quickly spread to the larger community. But because the CDC has also ordered up millions of doses of swine flu for distribution to begin at schools in mid-October, by gum they want to get the kids vaccinated first with the regular seasonal influenza shots.

That's because the swine flu vaccine is somewhere between a completely new vaccine and a regular seasonal influenza one. So while unexpected side effects might not be as drastic as for a completely new type of vaccine, the 2009 swine flu vaccine needs particularly careful monitoring.

The doses prepared for the NIH clinical tests on humans have already been tested on animals and will be given limited testing for human safety during the trials, which are just getting underway. But the major focus of the trials is to learn whether one or two doses, or more, will be needed to provide people with adequate antibodies against the swine flu virus.

The plan is to administer one shot to the volunteers, then review for any immediate side effects after eight days, then administer a second shot within 21 days of the first shot, then test again for antibodies. (See the CNN report at the link I provided for more details on the vaccine trials.)

So I'd surmise that the CDC and HHS want the schools open on time so that the first round of vaccinations, with the regular seasonal influenza vaccine, will have time to 'take' before the next round of shots with the new swine flu vaccine gets underway. It's hoped this will prevent any severe 'crossover' side effects from the seasonal vaccine and the swine flu one being given close together.

Although it's likely that the swine flu vaccination program will go ahead, the CDC - HHS have not yet given the green light. They're going to have to wait for the NIH clinical trials to wrap up and for the FDA to give final approval for the swine flu vaccines.

But adhering to the schedule of vaccinations at the schools for seasonal influenza, followed by swine flu vaccinations approximately six weeks later, would be especially important, given that more than one company will be providing the swine flu vaccine. That means there'll be minor variations in the swine flu vaccine lots, some of which might interact poorly with the seasonal influenza shot. Spacing the shots cuts down on this possibility no matter how remote it might be.

There's another angle. If the big swine flu outbreak in New York City this Spring is any indication, I'd say that parents of school-age children are sharply divided on the matter of school closings.

During the outbreak many New York parents demanded that their child's school be shut when an outbreak occurred there. Other parents demanded that the school stay open. This situation was repeated in other cities including Washington, DC.

The CDC got caught in the crossfire. They'd originally recommended that schools with an outbreak shut down. That touched off protests from working parents who couldn't afford day care for their children and/or who depended on the public school system to feed their children one square meal daily.

So the CDC back-tracked after a few days and told the schools to make decisions on a case-by-case basis.

That seems to be the same message the CDC and HHS sent to school authorities on Friday: decide on an individual basis whether to open or close schools. At the same time the HHS and the education department wanted to assure parents that a decision to open the schools on schedule, and keep them open during a swine flu outbreak, had the CDC's Stamp of Science, and was best for all concerned.

In this way they would be greasing the wheels of the seasonal flu vaccination program at the schools. And they'd be providing backup to parents who wanted to keep the schools open.

In summary, I'd guess that the mixed message reflects the government's attempt to thread the needle.

That exhausts my crystal ball gazing. The next question is whether it's indeed best for all concerned to open the schools on time, and keep them open even during a swine flu outbreak.

The answer is patently obvious if one studies the handy swine flu maps that Wikipedia publishes. (1) The maps show the exact location of swine flu outbreaks in a U.S. state.

Some states are reporting no swine flu activity, which means no regions within the state have an outbreak.

Ergo, if your region shows no outbreak activity a week before school is scheduled to reopen, school systems in the region can risk opening on time.

Schools in regions where there's a widespread swine flu outbreak should delay opening until the outbreak dies down.

Otherwise they could be looking at a logistical nightmare that would cause as much or more social disruption as delaying the school openings.

Part of the nightmare is that the non-pharmacological interventions (NPIs) the CDC recommends to help schools mitigate the effect of a swine outbreak are for the most part unrealistic or inadequate. See the updated guidelines at the CDC website for details but in my next post I'll list the recommended NPIs and highlight their flaws, some of which are quite serious.

I've saved the hardest question for last: Will there be enough swine flu vaccine doses available to vaccinate all the nation's schoolchildren in mid-October? Hopes are running high but we'll just have to cross that bridge when we come to it.

That might be another reason the federal government wants schools to open on time: it's possible there won't be enough vaccine until November or even later in the year.

The worst-case scenario in the event vaccine availability is very limited: the choice would be pretty much between keeping schools closed for almost half the school year or preparing to deal with cascading outbreaks of swine flu infections in the schools that will in turn engulf entire communities.

Best-case scenario: the virus will suddenly fizzle out of its own accord or mutate into something that's no worse than a summer cold.

We can't predict which scenario is more likely. That's because right now a microbe is running humanity's show.

For background on the federal government's thinking about school closures, see Spencer S. Hsu's August 4 report for The Washington Post titled Strategy On Flu Under Revision: Federal Officials to Put Less Emphasis on School Closing

Saturday, August 8

"This is the first time in my life that I can recall a government in North America organizing protests of one group of citizens against another. This is standard operating procedure in countries with left-wing governments."

The tactic is SOP for all repressive regimes, not just leftist ones. That Barack Obama's crew would deploy such a tactic will come as no surprise to those who've studied his political career and the careers of his handlers and closest associates.

For Americans who'd like to start catching up with reality, visit RBO ("The Real Barack Obama") and read the report that refers to the above quote.

Wednesday, August 5

“It is not just the fear of getting sick, but also the fear for the other.”

Physician DocJim and Bullmoosegal -- the biologist, former business manager and U.S. Army Reserve officer who blogs at The Mod Con -- have weighed in on proposed changes to U.S. federal guidelines for school closings in the face of an epidemic. See Spencer S. Hsu's great report today at The Washington Post for background.(1)

Below I've republished all the comments that DocJim and Bullmoosegal added to the Pundita comment section today relating to Hsu's report.(2) But in brief:

Bullmoosegal asks tough-minded questions about the cost-benefit angle of the damn-the-torpedoes decision to open U.S. schools on time during the swine flu epidemic.

DocJim proposes that officials adopt a "Delay and Pray" approach to the question of whether to keep schools open during the autumn phase of the epidemic:

Closings will give time to Delay and Pray which will lead to getting the hospitals through the first round of super-sick, so that there is room for another round -- that will mean more survivors.

Delay and Pray can give time for distribution of vaccines or anti-virals.

Delay and Pray may make the difference in life or death for your children or your husband or wife.

Bloomberg reports today that Brazil's government is using the same approach with good results -- and in this case the "pray" part is quite literal. A Brazilian priest in the Catholic Church has taken an enlightened, ethical position on the issue of 'social distancing' for Catholic priests and laity during the swine flu epidemic in Brazil.

Let us hope -- and pray -- that religious leaders in the USA and around the world follow his example. From the report filed by Bloomberg reporter Fabiola Moura (3):

[...] Brazilians are helping contain the swine flu in Latin America’s largest country by changing religious habits, canceling travel plans and extending school breaks.

Brazil, where 56 people have died of the pandemic H1N1 flu virus, has Latin America’s lowest mortality rate from the illness at 0.02 deaths per 100,000 people, compared with 0.41 in Argentina, 0.13 in Mexico and 0.11 in Chile, according to data as of July 29 from Brazil’s health ministry. The deaths in Brazil included 36 women, nine of whom were pregnant.

[...]

Government efforts to identify and isolate people infected with the virus and educate the public have helped curb the spread in Brazil, said Clelia Aranda, the coordinator of the Department of Disease Control in Sao Paulo.

“Our country is too big,” said Aranda, a pediatrician. “We need to have initiatives individualized to local realities, but without running away from a basic directive.”

In Brazil’s southern states, the area of the country that gets lower temperatures in winter, public schools delayed the return to classes after the winter break ends.[...]

See the rest of the report for details on the school closings. Now here we come to the enlightened part:

Brazilian priest Roberto Francisco Daniel tells his congregation not to hold hands while saying the Lord’s Prayer and to refrain from shaking hands and kissing in his morning mass to avoid getting swine flu.

“At least if you don’t have skin touching, you eliminate contact with secretions of somebody infected,” said the Roman Catholic priest, known as Padre Beto at the Nossa Senhora de Aparecida church in Bauru, about 300 kilometers (187 miles) west of Sao Paulo.

[...]

Even in Brazil, the country with the most Roman Catholics, Padre Beto considers outdated Saint Francis of Assisi’s habit, from the 1180s in Italy, of kissing wounds to cure the sick. “Francis’ act was medieval, as the extreme feast was,” he said. “It is a mystical exaggeration.”

Padre Beto, who also holds a doctorate in ethics from the Ludwig-Maximilian University in Munich and teaches in the law program of Instituicao Toledo de Ensino in Bauru, faced a dilemma when called to a hospital to bless a Catholic with the swine flu. He declined, following a recommendation from the hospital crew.

“Even religious matters need to have a limit,” Padre Beto said. “I asked them to tell her we were praying for her.”

See the report at the Bloomberg site for links to information about Padre Beto and his church.

I was also struck by this comment:

Maria Lucia Guedes, who works at Brazil’s state-run Banco do Brasil SA in Brasilia, canceled her family’s trip to Argentina in July, afraid of being infected. Her husband was uncomfortable traveling because a colleague was pregnant and “he thought it would be too much of a responsibility,” she said.

“It is not just the fear of getting sick, but also the fear for the other,” said Guedes, 49.

My hat's off to Guedes and her husband, and to Padre Betro. I wish a philanthropist would donate a boatload of Filligent's BioMasks to his church.

Doubtful the Padre knows anything the about BioMask™ but I will bet he'd be interested to learn that the mask prevents more than secretions from landing on people; it also prevents infection transmission through inhalation and exhalation of the swine flu virus.

The mask is also so breathable and comfy he'd be able to deliver a long homily while wearing one and the choir and congregation could sing through their BioMasks without sounding like a flock of honking geese.

That reminds me; there's an angle to the BioMask™ story that few outside John Batchelor's radio audience know about. When John interviewed Filligent co-founder/CEO Melissa Mowbray-D'Arbela on July 25, she revealed that her interest in developing the world's best pathogen-fighting mask was personal.(4)

She was pregnant and living in Hong Kong during the SARS outbreak there. She recalled the chaos as people fought over limited supplies of surgical masks -- masks that did very little to give protection against the SARS virus.

Guedes's comments point up that there's an ethical consideration to the issue of school closings, which economic arguments for keeping U.S. schools open don't take into account.

Of course school closings will be a hardship for many American parents, which is also an ethical consideration. Yet despite a CDC study showing that pregnant women are four times more likely than the general population to suffer serious complications from swine flu, U.S. officials have been reluctant to deliver public service announcements urging Americans to have "fear for the other."(5)

The issue came up during Glenn Beck's interview last week with John M. Barry, author of The Great Influenza: The Epic Story of the Greatest Plague in History. Beck asked whether swine flu parties were a good idea as a natural means of 'vaccinating' people against swine flu.

Barry replied that it was a judgment call but that the tie-breaker was to consider what would happen if you deliberately infected yourself then ended up standing next to a pregnant woman.

If the kind of people who run in front of four lanes of rush-hour traffic to save themselves a two minute walk to the pedestrian crossing want to risk death by infecting themselves with swine flu -- well, there's no law against it. But unless they're willing to self-quarantine after the swine flu party there are ethical considerations that extend beyond themselves.

The same considerations apply to infected American students flinging their swine flu germs around their pregnant mothers, pregnant aunts, pregnant school staff and pregnant members of the public. This doesn't even get into the subject of flinging swine flu onto Americans who are in other high-risk categories.

Of course germ sharing is a natural part of human life and death, but baseline consideration for the physical welfare of others during a pandemic is what distinguishes humans from lice.

Hello up there on the moon to U.S. officials, this is a pandemic virus -- you know: a special kind of virus? One of the traits of this special virus is that it doesn't read political polls.

Delay the opening of the public schools until you've figured out when the swine vaccination program will get underway. And start cranking out more PSAs about swine flu.

If PSA scriptwriters need inspiration to get in the proper mood for writing warnings about swine flu, I have a suggestion. They could listen to the podcast of John Batchelor's interview with Stephan Talty, author of The Illustrious Dead: The Terrifying Story of How Typhus Killed Napoleon's Greatest Army. BARF ALERT: If you have a delicate stomach best not to listen to the tale while eating.

1) The Washington Post: Strategy On Flu Under Revision: U.S. Officials to Put Less Emphasis on School Closings; Spencer S. Hsu; August 4, 2009

2) DocJim said...

The article by Spencer Hsu in the 08/04/09 "Washington Post" is well written. The Obama administration who were seldom quoted show an appalling lack of being helpful.

Schools closed for a week, even for another week when needed, might be the very thing to save many children and adults lives. True, this Mexican flu is not as bad as the feared Avian flu. But that doesn't mean we should sit by like the English and watch our children and adults die when the vaccine is delayed.

If the epidemic of Mexican swine flu is delayed significantly in the USA, then more people can be protected with the swine flu vaccine. Simple story. Even the nuanced Obama administration should be able to follow this one.

The angle that "widespread financial losses" from school closings might occur is a non-starter. Forget that one guys.

So far, the "helpfulness" of this administration to the nation has been a near-total and complete sham. The clunker program has been too successful, but nothing else has been worthy of bragging rights.

Delay and Pray.

The Obama administration (the federal government) is more concerned about financial shortfalls than deaths in their Mexican swine flu scenarios.

With this in mind, communities must fend for themselves. Five day closings of schools can delay the epidemic, albeit unlikely that it can defeat the epidemic.

Closings will give time to Delay and Pray which will lead to getting the hospitals through the first round of super-sick, so that there is room for another round--that will mean more survivors.

Delay and Pray can give time for distribution of vaccines or anti-virals.

Delay and Pray may make the difference in life or death for your children or your husband or wife.

Even if the boss is crabby when husband or wife stays home to care for the sick (or just out of school) child, there will be fewer cases of flu at that boss's business. There is a real dollar benefit for businesses to be generous in allowing the parents of sick (or about to be sick children) to stay home or work from home. Businesses need to think about this now and become psychologically prepared so that they will get through this period comfortably.

Bullmoosegal said...

[Re statements in Hsu's report:"Federal officials proposed school closings after studying the outbreaks of severe acute respiratory syndrome (SARS) and avian flu in Asia earlier this decade, examining the 1918 and 1957 flu pandemics and using new computer models to consider the data. But opponents of school closings said that the research relied on unrealistic assumptions and overlooked real-world factors.]"

One wonders which 'real-world' factors they refer to. That closures extend the school year, and cost more for extended teacher contracts, cleaning, etc.? If so, these need to be spelled out. Any cost-benefit and risk analyses (which have yet to be done at all as far as I can see) need to clearly spell out all likely options, costs of implementation of those options plus variants, risks of full implementation versus something else, etc. Otherwise decision-making is purely ad hoc and knee-jerk, something they say they want to avoid.

4) Pity the interview is no longer at the podcast section on John's website else I'd post a link to it here. But for those who keep track of such things, the interview started around the 10 minute mark, Hour 2 of the July 25 podcast. I hope John is archiving all his show's podcasts because it seems he only keeps them on the website for a couple weeks.